Cigna Dental Benefit Summary
Cigna
A Cigna Dental Choice PPO plan offering Class I (Diagnostic & Preventive) and Class II (Basic Restorative) benefits with a $1,250 annual maximum. Members may see any licensed dentist, but using an in-network provider minimizes out-of-pocket costs.
Plan Overview
| Benefit | In-Network (Total Network) | Out-of-Network (See Non-Network Reimbursement) | ||
|---|---|---|---|---|
| Plan Pays | You Pay | Plan Pays | You Pay | |
| Plan Maximums & Deductibles | ||||
| Policy Year Benefits Maximum (Class I & II) | $1,250 | $1,250 | ||
| Reimbursement Level | Based on Contracted Fees | Maximum Reimbursable Charge (90th percentile) | ||
| Annual Deductible — Individual | $50 | $50 | ||
| Annual Deductible — Family | $150 | $150 | ||
| Class I: Diagnostic & Preventive | ||||
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Oral Evaluations 2 per policy year |
100% — No Deductible | No Charge | 100% — No Deductible | No Charge |
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Prophylaxis: Routine Cleanings 2 per policy year; includes periodontal maintenance procedures following active therapy |
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X-rays: Routine (Bitewing) 2 per policy year |
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X-rays: Non-Routine (Complete Series / Panoramic) Limited to a combined total of 1 per 36 months |
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Fluoride Application 1 per policy year; children under age 19 only |
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Sealants (per tooth) Limited to posterior tooth; 1 treatment per tooth every 36 months; children under age 14 only |
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Space Maintainers (non-orthodontic) Limited to non-orthodontic treatment; children under age 19 only |
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| Class II: Basic Restorative | ||||
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Emergency Care to Relieve Pain Administered at in-network coinsurance level regardless of provider |
80% After Deductible | 20% After Deductible | 80% After Deductible | 20% After Deductible |
| Restorative: Fillings | ||||
| Oral Surgery: Minor | ||||
| Anesthesia: General and IV Sedation | ||||
For services provided by a Cigna Dental PPO network dentist, Cigna Dental will reimburse the dentist according to a Fee Schedule or Discount Schedule.
For services provided by a non-network dentist, Cigna Dental will reimburse according to the Maximum Reimbursable Charge. The MRC is calculated at the 90th percentile of all provider allowed amounts in the geographic area. The dentist may balance bill up to their usual fees.
All deductibles, plan maximums, and service specific maximums cross accumulate between in-network and out-of-network. Benefit frequency limitations are based on the date of service and cross accumulate between in and out of network.
Pretreatment review is available on a voluntary basis when dental work in excess of $200 is proposed.
When more than one covered Dental Service could provide suitable treatment based on common dental standards, Cigna will determine the covered Dental Service on which payment will be based and the expenses that will be included as Covered Expenses.
The Cigna Dental Oral Health Integration Program offers enhanced dental coverage for customers with certain medical conditions. There is no additional charge to participate in the program. Those who qualify can receive reimbursement of their coinsurance for eligible dental services. Eligible customers can also receive guidance on behavioral issues related to oral health. Reimbursements under this program are not subject to the annual deductible, but will be applied to the plan annual maximum. For more information on how to enroll and a complete list of terms and eligible conditions, go to www.mycigna.com or call customer service 24/7 at 1-800-Cigna24.
Out of network claims submitted to Cigna after 365 days from date of service will be denied.
- Employees seeking basic preventive and restorative dental coverage at a lower cost
- 👨👩👧👦Dependents covered up to age 26
- ✅Guarantee Issue — no medical exam required